UROLOGY PEDS

WHICH TESTICLE IS MOST AFFECTED IN CRYPTOCHIDISM

RIGHT TESTICLE

Crescent formation on light microscopy

Rapidly progressive glomerulonephritis crescent formation on biopsy due to fibrin and plasma protein deposition

phimosis

stenosis or narrowing of foreskin so that it cannot be retracted over the glans penis Phimosis is an inability to retract the foreskin foreskin in normal position and cannot be retracted

What is the treatment of testicular torsion?

surgery within 6 hours Surgical detorsion and bilateral orchiopexy to the scrotum

hypospadias treatment

surgical reconstruction Treatment is surgical repair, usually performed before 1-2 years of age Do not circumcise - foreskin may be used to reconstruct the urethra

cryptorchidism

undescended testicles! risk factor for testicular cancer later in life. Teach self exam for boys around age 12--most cases occur in adolescence ↑ Risk in premature infants 30% vs. 5% in full-term infants An undescended testicle is generally rare in full-term babies but common in baby boys born prematurely (30%) If not repaired risks infertility and malignancy Cryptorchidism is the failure of testes to descend (one or both)

vesicoureteral reflux DIAGNOSIS

voiding cystourethrogram (VCUG) + renal imaging Diagnose by using VCUG and monitor by using serial ultrasonography and VCUGs

c-ANCA

wegener's granulomatosis. URI + Pulmonary + Renal Involvement. necrotizing granulomas.

voiding cystourethrogram

x-ray image (with contrast) of the urinary bladder and urethra obtained while the patient is voiding

S. saprophyticus

young individuals who are biologically female, sexually active Common in women, in whom cases of uncomplicated cystitis are often preceded by sexual intercourse (honeymoon cystitis)

Membranoproliferative glomerulonephritis diagnosis

↓ serum C3 and C4 levels

Patient will present as → a healthy newborn male is undergoing routine examination, upon examination of the genitalia the urethral meatus is found located proximal to the tip of the glans on the ventral aspect of the penile shaft.

Hypospadias

TESTICULAR TORSION causes

More common in patients with a history of cryptorchidism Often after vigorous activity or minor trauma Usually in post pubertal boys: 65% occur in boys ages 10-20 years old

What colony-forming unit count number is used to diagnose urinary tract infections?

A colony-forming unit count in the urine of greater than (number) 100,000 is used to diagnose urinary tract infections like cystitis

Membranoproliferative glomerulonephritis

"Tram-track" appearance on LM MPGN describes an injury to the glomerulus secondary to immune-complex deposition and/or a complement-mediated mechanism ↓ serum C3 and C4 levels

Membranoproliferative glomerulonephritis

"Tram-track" appearance on LM MPGN describes an injury to the glomerulus secondary to immune-complex deposition and/or a complement-mediated mechanism Deposition of immune-complexes or complement proteins results in an inflammatory response that leads to glomerular injury In response to this injury, the cell undergoes a number of changes such as mesangial proliferation, remodeling of the capillary wall, and development of a new basement membrane MPGN can be idiopathic or result from a secondary condition, such as hepatitis C virus (HCV) infection ↓ serum C3 and C4 levels

Patient will present as → a 26-year-old man who presents with hematuria, periorbital edema, and jaundice. He has a medical history of opioid use disorder with prior hospitalizations for a heroin overdose. He is on Suboxone but is non-adherent. His blood pressure is 162/102 mmHg. Physical examination is significant for scleral icterus, hepatomegaly, and palpable purpura. Serology shows decreased C3 and C4 levels and elevated anti-hepatitis C antibodies. Urinalysis demonstrates dysmorphic red blood cells and red blood cell casts

(Membranoproliferative glomerulonephritis).

Patient will present with → entrapment of the foreskin in the retracted position

(paraphimosis)

Henoch-Schonlein Purpura

(tetrad of rash, arthralgias, abdominal pain, and renal disease)

Wegener's granulomatosis with polyangiitis

- sinuses, lungs and kidneys - nasal perforation and cavitary lung lesions - cANCA

How is cryptorchidism treated?

-Observation: in < 4-6 months (Most descend spontaneously-70%) -Orchiopexy: recommended as early as > 4-6 months performed before 1 year is best

A 1-day-old male infant born by normal spontaneous vaginal delivery was found to have a scrotal mass on physical examination. The mass transilluminates and confirms your suspicion of hydrocele. How long should you recommend that the parents wait before the hydrocele is reassessed?

1 YEAR

CYSTITIS SYMPTOMS

1) urinary frequency 2) urgency 3) burning 4) dysuria **Young, otherwise healthy women are the most common case presented. fever, frequency, urgency, dysuria, incontinence, abdominal pain, and hematuria Strong, foul-smelling or cloudy urine may be noted

Enuresis treatment

1. reassurance, resolves spontan, normal 4-5 yo 2. *desmopressin* (DDVAP) 3. imipramine TX: Patients younger than 5 years of age do not require investigation or treatment; patients and family should be informed that bed-wetting is normal at their age and will likely resolve with time. Behavioral modification: Nighttime audio alarm that sounds as soon as the child starts to urinate, eventually conditioning controlled bladder emptying before enuresis Medications: Desmopressin acetate (DDAVP) acts to concentrate the urine. If given in the evening, less urine is produced overnight, decreasing the likelihood of wetting

Testicular torsion is most common in which age group?

12 to 18-year olds. Two-thirds of the cases occur in this age group. The next most common group is newborns.

How much time is available from the onset of symptoms to detorse the testicle?

6 hours will bring about the best results; > 90% salvage rate

At what age is it necessary to perform orchiopexy in a child affected with cryptorchidism?

6-12 months

How much time is available from the onset of symptoms to detorse the testicle?

< 6 hours will bring about the best results (> 90% salvage rate). There is a < 10% chance of salvaging the testicle after 24 hours.

hydrocele

A hydrocele is a mass of the fluid-filled congenital remnants of the tunica vaginalis, usually resulting from a patent processus vaginalis Painless scrotal swelling (hydroceles are the most common cause of painless scrotal swelling) Infants: will usually close within the 1'st year of life may require elective repair as clinically indicated (+) Transillumination vs. Tumor or varicocele which both do not transilluminate

Patient will present as → a 15-year-old boy who comes to the office because of malaise, anorexia, nausea, and decreased urination. His mother says that he is having problems hearing. Physical examination shows decreased hearing bilaterally with the Rinne test and bilateral edema in the lower extremities. Urinalysis shows microscopic hematuria and proteinuria. A peripheral blood smear reveals microcytic anemia.

ALPORT SYNDROME

What is the classic history?

Acute onset of scrotal pain usually after vigorous activity or minor trauma

Anterior Lenticonus

Alport syndrome

What is the most common etiology of cystitis in elderly males?

An enlarged prostate is the most common etiology of cystitis in elderly males.

What is the appropriate management of IgA nephropathy?

Most patients will benefit from ACE-I or ARB to reduce proteinuria and BP, as well as a statin. Patients with nephrotic range proteinuria may also benefit from the addition of fish oil, while patients with more severe disease require immunosuppression

What is the pathogenesis of Goodpasture syndrome?

Antibody formation to the a 3 chain of type IV collagen in the GBM

What is the appropriate management of Goodpasture syndrome?

Apheresis, high-dose IV steroids, and cyclophosphamide

TESTICULAR TORSION SYMPTOMS

Asymmetric high riding testicle "bell clapper deformity" negative Prehn's sign (lifting of testicle will not relieve pain). Teenage males. Sudden, severe pain and swelling in the testicle are symptoms. Associated with nausea and vomiting Very tender to palpation. Cremaster reflex absent Negative Prehn's sign (lifting of testicle will not relieve pain) Loss of cremasteric reflex (elevation of the testes in response to stroking of the inner thigh)

vesicoureteral reflux

Backflow of urine from the urinary bladder to the ureters. Vesicoureteral reflux (VUR) is detected in 30-50% of children presenting with a UTI at < 1 y/o The American Academy of Pediatrics (AAP) recommends RBUS for all infants and children 2 to 24 months following their first febrile UTI Children of any age with recurrent febrile UTIs

Patient will present as → a 10-year-old girl who comes to the clinic with her mother because of dysuria and suprapubic pain for the past two days. She is usually healthy, has received her childhood immunizations, and has had no previous episodes of this kind. Physical examination is normal. Urinary dipstick is positive for leukocytes and nitrites.

CYSTITIS

Patient will present as → a 34-year-old woman with a 3-day history of hematuria, dysuria, increased urinary frequency, and nocturia. She has had no fever, chills, or back pain. On examination, she does not look ill. Her temperature is 37.5 ° C. Her abdomen is nontender. There is no CVA tenderness.

CYSTITIS

IgA nephropathy - diagnosis?

Caused by IgA immune complexes which are the first line of defense in respiratory and GI secretions so infections cause an overproduction which then damages the kidneys Diagnosed by (+) IgA deposits in mesangium and with immunostaining

cystitis treatment

Cephalosporin x 14 days are the first-line oral agent in the treatment of UTI in children without genitourinary abnormalities First-generation cephalosporin (Keflex 50-100 mg/kg BID) for low risk of renal involvement

What is cryptorchidism?

Condition in which one or both testicles remain in the body cavity. Cryptorchidism is the failure of testes to descend - undescended testicle - (one or both)

What is the best initial management of vesicoureteral reflux?

Conservative treatment - Mild to moderate VUR often resolves spontaneously, but the more serious disease may require surgical intervention

When do congenital hydroceles need repair?

Most resolve in the first year of life. Persistence suggests the presence of a patent indirect hernia sac that should be repaired. So, if after 1 year to 18 months they do not reduce in size or become larger, surgery is indicated.

RBC casts

Nephritic syndrome

a one-year-old child who is brought to your office for his 12-month visit. You note that the boy's testicles are inappreciable on the exam. The medical record reports that the child's testicles had been examined at two previous visits. The mother is very concerned and asks if her son will need surgery.

Cryptorchidism

Post-infectious glomerulonephritis PRESENTATION

Cx: smoky, tea coloured urine Tx: Supportive Treatment self-resolving Group A strep (skin or throat) - 10-14 days after infection - treatment is supportive + antibiotics Group A streptococcal skin infection 3-6 weeks prior Throat infection 1-3 weeks prior 1. Postinfectious - Group A strep (skin or throat) - 10-14 days after infection - diagnosed with ASO titers and low serum complement - treatment is supportive + antibiotics Group A streptococcal skin infection 3-6 weeks prior Throat infection 1-3 weeks prior + ASO titers Serum C3 and C4 can be low

In addition to dysuria, cystitis causes pain where?

Cystitis causes pain in the suprapubic region of the abdomen

cystitis

Cystitis is an infection of the bladder Characterized by dysuria (painful urination) WITHOUT urethral discharge frequent urination/urgency, +/- hematuria Abdominal or suprapubic pain New-onset incontinence (in toilet-trained children) Absence of fever, chills, or flank pain The most common cause is E. coli (80%) - gram-negative - Klebsiella; Proteus; Enterobacter; Citrobacter Common in women, in whom cases of uncomplicated cystitis are often preceded by sexual intercourse (honeymoon cystitis) In men, a bacterial infection of the bladder is usually complicated and usually results from ascending infection from the urethra or prostate or is secondary to urethral instrumentation The most common cause of recurrent cystitis in men is chronic bacterial prostatitis

What are the characteristics of glomerular disease?

Proteinuria, hematuria (microscopic or gross), renal insufficiency, and HTN. Depending upon the cause, systemic symptoms may also be present.

CYSTITIS

Cystitis is when the infection is limited to the bladder Girls have a 10-fold risk over boys Cystitis is an infection of the bladder Characterized by dysuria (painful urination) WITHOUT urethral discharge frequent urination/urgency, +/- hematuria Abdominal or suprapubic pain New-onset incontinence (in toilet-trained children) Absence of fever, chills, or flank pain

What is the pathogenesis of Alport syndrome?

Defects in a3, a4, or a5 chains in type IV collagen in GBM (and elsewhere)

hypospadias diagnosis

Diagnosis is usually made during the newborn exam but imaging studies (excretory urogram) can aid in the diagnosis

How is the diagnosis of testicular torsion made?

Doppler US is the diagnostic imaging study of choice. However, emergent surgical exploration by a urologist should never be delayed in order to obtain diagnostic imaging

What are the characteristic laboratory findings of Wegener granulomatosis?

Elevated BUN and serum creatinine, positive ANCA (usually c-ANCA or anti-proteinase 3), t t ESR and CRP, hy pocomple- mentemia, urinary sediment with dysmorphic RBCs, RBC casts, and protein (usually nonnephrotic range)

How does cryptorchidism present?

Empty, small scrotum, +/- inguinal fullness MC in inguinal canal

Nephritic syndrome

Hallmark is glomerular inflammation and bleeding 1.) LIMITED proteinuria 2.) Oliguria and Azotemia 3.) Salt retention -- periorbital edema and hypertension(salt/fluid retention) 4.) RBC casts and dysmorphic RBCs in urine-- Immune Complex deposition activated Complement; C5a attracts neutrophils which mediate the damage Nephritic syndrome: moderate proteinuria 1-3.5 g/day Hematuria, hypertension, and oliguria. Acute glomerulonephritis is an inflammation of glomeruli causing protein and RBC leakage into the urine, typically caused by an immune response

What are the most common causes of secondary MPGN?

Hepatitis B/C, cryoglobulinemia, lupus, and HIV and drug use

enuresis diagnosis

Enuresis should first be tested with a urinalysis and urine culture to rule out infection Then, a thorough history and physical with fluid intake, stool, and voiding diary should be compiled in order to investigate abnormal patterns seen in conditions like constipation or diabetes insipidus

What is epispadias?

Epispadias is an abnormal urethra opening on the dorsal (back/top) surface of the penis. (think of the penis as a shark to remember the dorsal vs. ventral surface)

MOST COMMON CAUSE OF CYSTITIS

Escherichia coli Escherichia coli is the most common bacterial pathogen in cases of urinary tract infection in children.

Alport syndrome presentation

Eye problems (eg, retinopathy, lens dislocation), glomerulonephritis, sensorineural deafness --> *Can't see, Can't pee, Can't hear a bee* (not to be confused with *Reiter's syndrome* can't see, can't pee, can't climb a tree) isolated hematuria, sensory hearing loss, and ocular disturbances Presents as isolated persistent hematuria A genetic condition that occurs in children resulting in renal failure and hearing loss Ophthalmologic exam reveals anterior lenticonus - anterior part of the lens has a conical shape

CYSTITIS RISK FACTORS

Female gender > 65 years Catheterization Diabetes mellitus Urinary stasis The most significant risk factor is the presence of a urinary tract abnormality that causes stasis, obstruction or reflux

What is a hydrocele?

Fluid collection within tunica vaginalis (a serous membrane that covers the testicle and internal surface of scrotum) Associated with incomplete closure of processus vaginalis leading to communication with peritoneal cavity (infants) or blockage of lymphatic drainage (adults) Presents as scrotal swelling that can be transilluminated

A 22-year-old woman comes to the office because her urine is cola-colored and she has not urinated since yesterday morning. Her past medical history is significant for pharyngitis two weeks ago. Her mother and grandmother have type 2 diabetes. Her blood pressure is 146/92 mmHG. On physical examination, she has edema of her face and hands. Which of the following is the most likely diagnosis?

Glomerulonephritis

A 27-year-old male presents to the clinic complaining of coughing up small amounts of blood daily for the past week. He denies smoking, sick contacts, or recent travel. Chest radiographs demonstrate interstitial pneumonia with patchy alveolar infiltrates suggestive of multiple bleeding sites. Urinalysis is positive for blood and protein. A positive result is returned for anti-glomerular basement membrane antibody (anti-GBM Ab)

Goodpasture syndrome

Anti-GBM antibodies

Goodpasture syndrome (glomerulonephritis and hemoptysis)

Linear immunofluorescence in RPGN

Goodpasture's disease

What is the typical clinical presentation of IgA nephropathy?

Gross hematuria with or without proteinuria during viral upper respiratory tract infection or GI illness, persistent microscopic hematuria, and sometimes associated dull flank pain, with a 2:1 male predominance, often presenting in the second and third decades of life

A 4-year-old boy presents with a painless mass in his scrotum that fluctuates in size with palpation. The mass transilluminates. What is the probable diagnosis?

HYDROCELE

Patient will present as → a 1-day-old male infant born by normal spontaneous vaginal delivery was found to have a scrotal mass on physical examination. The mass transilluminates and confirms your suspicion of hydrocele.

HYDROCELE

A 15-year-old man comes to the office with acute onset of nausea, severe pain and swelling within the right testis. He has no fever or irritative voiding symptoms. Which of the following scrotal physical examination findings would you expect in this patient?

High-lying testis

Post-infectious glomerulonephritis DIAGNOSIS

RBC casts are common, hematuria, proteinuria diagnosed with ASO titers and low serum complement + ASO titers Serum C3 and C4 can be low

Upon genital examination of a newborn male, the urethral meatus is found located proximal to the tip of the glans on the ventral aspect of the penis. This finding is defined as which of the following conditions?

Hypospadias Hypospadias is a congenital anomaly defined by the location of the urethral meatus on the ventral surface of the penis located proximal to the glans. Epispadias is when the meatus is located on the dorsal surface of the penis.

What is hypospadias?

Hypospadias is an abnormal urethral opening on the ventral surface of the penis.

Patient will present as → a 33-year-old man who comes to the ED because of blood in his urine for 2 days. He has also been feeling unwell, with a sore throat, running nose, cough, and fever. Medical history includes three episodes of hematuria in the past that have spontaneously resolved. His temperature is 98.9°F; pulse is 82/min; respirations are 18/min, and blood pressure is 145/90 mm Hg. PE is normal. Urinalysis shows moderate numbers of erythrocytes, a few leukocytes, red cell casts, and a large amount of protein. No bacteria are cultured. A renal biopsy demonstrates large dark mesangial deposits.

IGA NEPHROPATHY ( BERGER DISEASE)

What is the definitive management of phimosis?

If conservative measures are ineffective circumcision is the definitive treatment

A 33-year-old man comes to the ED because of blood in his urine for 2 days. He has also been feeling unwell, with a sore throat, running nose, cough, and fever. Medical history includes three episodes of hematuria in the past that have spontaneously resolved. His temperature is 98.9°F; pulse is 82/min; respirations are 18/min, and blood pressure is 145/90 mm Hg. PE is normal. Urinalysis shows moderate numbers of erythrocytes, a few leukocytes, red cell casts, and a large amount of protein. No bacteria are cultured. A renal biopsy demonstrates large dark mesangial deposits.

IgA nephropathy

A 9 year-old boy who has had cold-like symptoms for the past few days is brought to the clinic by his mother who states that her son had gross hematuria this morning. Prior to the cold-like symptoms the boy has been in excellent health. He is up-to-date on all of his immunizations. The patient does not have any edema, hypertension or purpura. Urinalysis reveals the urine to be cola-colored with a 2+ positive protein and 2+ hemoglobin. Microscopic analysis reveals 50-100 RBCs/HPF, no WBCs, bacteria, casts or crystals. What is the most likely diagnosis

IgA nephropathy

IgA deposits in mesangium

IgA nephropathy

MOST COMMON CAUSE OF GLOMERULONEPHRITIS

IgA nephropathy

mesangial deposits - diagnosis?

IgA nephropathy (Berger's disease)

Henoch-Schonlein Purpura (HSP) symptoms

IgA type III hypersensitivity → vasculitis/nephropathy, palpable purpura + arthralgias + GI symptoms, often follows URI (immediately, not delayed like PSGN) A tetrade of rash, arthralgia, abdominal pain and kidney disease in a child

VESICOURETERAL REFLUX TREATMENT

In most cases of VUR, conservative, nonoperative therapy is effective in controlling infection; surgery to correct the anatomy if severe, give fluids, LOW DOSE LONG TERM ABX Mild to moderate VUR often resolves spontaneously, but the more serious disease may require surgical intervention

What is paraphimosis?

Inability to replace the foreskin back over the glans in an uncircumcised male is the entrapment of the foreskin in the retracted position => it is a medical emergency If the retracted foreskin is somewhat tight, it functions as a tourniquet, causing the glans to swell, both blocking the foreskin from returning to its normal position and worsening the constriction. Paraphimosis can occur when the foreskin is left retracted (behind the glans penis)

What is phimosis?

Inability to retract the foreskin from the penis In adults, phimosis may result from scarring after trauma, infection (such as balanitis), or prolonged irritation

In addition to dysuria, what are some clinical complaints of patients with cystitis?

Irritative voiding symptoms, such as urinary frequency, and urgency. Low back pain and suprapubic pain, cloudy/foul-smelling urine, and hematuria are also common symptoms

What are the lab findings of acute bacterial cystitis?

Lab findings of acute bacterial cystitis include positive leukocyte esterase and nitrites.

What is the typical clinical presentation of Goodpasture syndrome?

Malaise, rapidly progressive renal failure, anemia, hemoptysis and pulmonary hemorrhage

glomerulonephritis diagnosis

Manifestations: proteinuria, HTN, azotemia, oliguria (< 400 ml urine/day), hematuria (RBC casts are hallmark) Edema is not as much as in nephrotic syndrome Urinalysis: proteinuria < 3.5 grams per day (24-hour urine), hematuria, RBC casts Biopsy: hypercellular, immune complex deposition

A 26-year-old man presents with hematuria, periorbital edema, and jaundice. He has a medical history of opioid use disorder with prior hospitalizations for a heroin overdose. He is on Suboxone but is non-adherent. His blood pressure is 162/102 mmHg. Physical examination is significant for scleral icterus, hepatomegaly, and palpable purpura. Serology shows decreased C3 and C4 levels and elevated anti-hepatitis C antibodies. Urinalysis demonstrates dysmorphic red blood cells and red blood cell casts

Membranoproliferative glomerulonephritis (MPGN)

Rapidly progressive glomerulonephritis

Nephritic syndrome that progresses to renal failure in weeks to months. Goodpasture's syndrome: (+) anti-GBM antibodies, dx linear IgG deposits, treat with high dose steroids, plasmapheresis + cyclophosphamide Vasculitis - lack of immune deposits (+) ANCA antibodies Microscopic polyangiitis (+) P-ANCA Granulomatosis with polyangiitis (Wegener's) (+) C-ANCA

A 26 year-old woman comes to the office for her first prenatal visit at 9 weeks gestation. During evaluation, her urinalysis reveals asymptomatic bacteriuria. Which of the following antibiotics is the preferred treatment in this patient?

Nitrofurantoin (Macrobid)

CYSTITIS TREATMENT

Nitrofurantoin (or fosfomycin) TMP/SMX if resistance is low Cefixime Cephalosporin x 14 days are the first-line oral agent in the treatment of UTI in children without genitourinary abnormalities First-generation cephalosporin (Keflex 50-100 mg/kg BID) for low risk of renal involvement

What are the characteristic laboratory findings of IgA nephropathy?

Normal or decreased renal function, persistent microhematuria, and variable proteinuria; urine sediment reveals dysmorphic RBCs and RBC casts

SECONDARY VESICOURETERAL REFLUX

Occurs due to a urinary tract malfunction, often caused by abnormally high pressure inside the bladder In secondary vesicoureteral reflux, there's an obstruction at some point in the urinary tract that causes an increase in pressure, causing urine to flow backward into the ureters or kidneys Secondary vesicoureteral reflux is most commonly caused by recurrent urinary tract infections Other causes include posterior urethral valve disorder, and neurogenic bladder

IGA NEPHROPATHY AGE POPULATION

Often affects young males within days (24-48 hours) after URI or GI infection

Patient will present with → foreskin in normal position that cannot be retracted

PHIMOSIS

Patient will present as → a 10 y/o is brought to the clinic with her mother for dark urine. The mother mentions that the child was complaining of sore throat and cough/cold symptoms two weeks ago. The urine shows gross hematuria without nitrites or leukocytes.

POST INFECTIOUS GLOMERULONEPHRITIS

HYDROCELE SYMPTOMS

Painless scrotal swelling (hydroceles are the most common cause of painless scrotal swelling) Hydrocele is common in newborns and typically disappears without treatment during the first year of life. A hydrocele is a mass of the fluid-filled congenital remnants of the tunica vaginalis, usually resulting from a patent processus vaginalis

Which of the following conditions is defined as the inability to reduce the foreskin of the penis once it has been retracted?

Paraphimosis

What are the causes cause paraphimosis?

Paraphimosis most commonly occurs when a healthcare professional forgets to pull the foreskin back to its normal position after a medical examination or procedure. Other causes of paraphimosis include having an infection, physical trauma to the genital area, pulling the foreskin back too forcefully, having a foreskin that's tighter than normal, having a foreskin that has been pulled back for an extended period

RED BLOOD CELL CASTS

Pathognomonic for glomerulonephritis

Which of the following agents can be used as a urinary analgesic?

Phenazopyridine (Pyridium

glomerulonephritis treatment

Positive streptococcal cultures are treated with appropriate antibiotic therapy. Steroids and other immunosuppressive drugs may be used to control the inflammatory response Dietary management: salt and fluid restriction Hypertension when present can be severe, requiring vasodilators, diuretics, and fluid restriction Dialysis should be performed if symptomatic azotemia IgA nephropathy - glucocorticoids Rapidly progressive glomerulonephritis - immunosuppressive therapy Use medications to control hyperkalemia, pulmonary edema, peripheral edema, acidosis and hypertension May require renal transplant - most syndromes recur in the transplanted kidney

A 10 y/o is brought to the clinic with her mother for dark urine. The mother mentions that the child was complaining of sore throat and cough/cold symptoms two ago. The urine shows gross hematuria without nitrites or leukocytes.

Postinfectious (Poststreptococcal) glomerulonephritis

What are some risk factors for cryptorchidism?

Premature infants - ↑ Risk in premature infants 30% vs. 5% in full-term infants - Low birth weight

What is the typical clinical presentation of postinfectious GN?

Presentation varies from asymptomatic with only microscopic findings on urinalysis to that of a nephritic syndrome: gross hematuria, HTN, edema, and acute renal failure. Symptoms appear 2-3 weeks after streptococcal pharyngitis or other bacterial infection

What are the two types of vesicoureteral reflux (VUR)

Primary vesicoureteral reflux is the most common type and happens when a child is born with a defect at the ureterovesical junction In secondary vesicoureteral reflux, there's an obstruction at some point in the urinary tract that causes an increase in pressure, causing urine to flow backward into the ureters or kidneys

What are the characteristic laboratory findings of Goodpasture syndrome?

Rapidly rising BUN/serum creatinine; proteinuria (usually nonnephrotic); and positive anti-GBM antibodies, occasionally positive ANCA, and normal complement levels. Urine sediment contains dysmorphic RBCs and RBC casts

Which of the following history findings would trigger a workup for vesicoureteral reflux in a young female patient?

Recurrent cystitis Particularly in young female patients, any history that points to recurrent infection, especially cystitis or pyelonephritis, should trigger an evaluation for vesicoureteral reflux (VUR).

Paraphimosis treatment

Reduction of the foreskin done with lubrication and gentle traction. Can be a surgical emergency. (ouch) Treat by applying firm circumferential compression to the glans with the hand Paraphimosis → should be regarded as an emergency because constriction leads quickly to vascular compromise and necrosis of the glans penis Firm circumferential compression of the glans with the hand may relieve edema sufficiently to allow the foreskin to be restored to its normal position. If this technique is ineffective, a dorsal slit done using a local anesthetic relieves the condition temporarily. Circumcision is then done when edema has resolved

vesicoureteral reflux DIAGNOSIS

Renal and bladder ultrasonography (RBUS)

A 21-year-old female presents with dysuria. On examination of the urine, many squamous epithelial cells are noted. Which of the following is the next best step in the evaluation or treatment of this patient?

Repeat urinalysis with a clean catch sample The presence of many squamous epithelial cells indicates contamination with vaginal flora. The test should be repeated with a clean catch specimen.

Cryptorchidism is most common in which testicle?

Right-side testicle

Membranoproliferative glomerulonephritis causes

SLE, viral hepatitis MPGN can be idiopathic or result from a secondary condition, such as hepatitis C virus (HCV) infection

What might cause phimosis?

Scarring after trauma or infection (such as balanitis)

HYDROCELE DIAGNOSIS

Scrotal ultrasound can be used in the diagnosis of both hydrocele and varicocele The hydrocele can be visualized with transillumination Tumor or varicocele which both do not transilluminate

What is the typical clinical presentation of Alport syndrome?

Sensorineural hearing loss, ocular abnormalities (anterior lenticonus, corneal dystrophy, perimacular flecks); persistent microscopic hematuria, and renal failure

What is the typical clinical presentation of Wegener granulomatosis?

Sinusitis, cough, dyspnea, hemoptysis, migratory pulmonary infiltrates, hematuria or tea-colored urine, proteinuria, and renal insufficiency

Glomerulonephritis Treatment

Steroids and immunosuppressive drugs may be used to control the inflammatory response Dietary management: salt and fluid restriction Dialysis should be performed if symptomatic azotemia ACEI/ARBs (enalapril or losartan) are renoprotective - blood pressure goal < 130/80In poststreptococcal GN Nifedipine is used instead of ACEI (ACE may cause hyperkalemia) IgA nephropathy - Glucocorticoids Rapidly progressive glomerulonephritis - immunosuppressive therapy

What is the non-definitive management of phimosis?

Stretching, topical corticosteroids for 4-8 weeks, proper hygiene

testicular torsion treatment

Surgical emergency: Repair both testes within 4-6 hours Orchiopexy

What are the symptoms of testicular torsion?

Swelling. Severe pain. One testicle more elevated than the other. Pain in the scrotum, suprapubic pain

Patient will present as → a 15-year-old boy with severe lower abdominal pain that awoke him from sleep about 3 hours ago. The pain is sharp and radiates to the left thigh. While in the emergency room, the patient experiences one episode of vomiting. He denies any fever, dysuria, or chills. The mom reports a childhood history of cryptorchidism. Physical examination reveals normal vitals with blood pressure 100/60 and a temperature of 98.6F. The abdominal examination is relatively benign. Scrotal examination reveals an elevated left testis that is diffusely tender. Lifting of the left testicle does not relieve pain and there is a loss of a cremasteric reflex. Transillumination test is negative. Doppler ultrasound shows absent blood flow.

TESTICULAR TORSION

What are some complications of cryptorchidism?

Testicular cancer (in both testicles)-Testicular torsion-Subfertility-Inguinal hernia

cryptorchidism RISK FACTOR

Testicular carcionoma If not repaired risks infertility and malignancy Complications of undescended testes is testicular cancer (in both descended and undescended testes) or infertility (which occurs in up to 75% of male children with bilateral cryptorchidism and in 50% of male children with unilateral cryptorchidism.)

What is the first-line antibiotic used for the prophylaxis against urinary tract infections in children with vesicoureteral reflux?

Trimethoprim-sulfamethoxazole is the first-line antibiotic used for the prophylaxis against urinary tract infections in children with vesicoureteral reflux

What is testicular torsion?

Testis is abnormally twisted on its spermatic cord which compromises arterial supply and venous drainage leading to ischemia. Surgical emergency! Torsion (twist) of the spermatic cord, resulting in venous outflow obstruction, and subsequent arterial occlusion and infarction of the testicle Twisting of the spermatic cord that results in compromised blood flow and ischemia - this is considered a surgical emergency Often after vigorous activity or minor trauma Usually in post pubertal boys: 65% occur in boys ages 10-20 years old Asymmetric high riding testicle "bell clapper deformity" Negative Prehn's sign (lifting of testicle will not relieve pain) Loss of cremasteric reflex (elevation of the testes in response to stroking of the inner thigh)

What is the best initial test for the diagnosis of cystitis?

The best initial test for the diagnosis of cystitis is urine analysis.

How is the diagnosis of vesicoureteral reflux established?

The diagnosis of vesicoureteral reflux is established by performing voiding cystourethrogram

What is the most common cause of secondary vesicoureteral reflux?

The most common cause of secondary vesicoureteral reflux is recurrent urinary tract infections

What is the second most common cause of uncomplicated urinary tract infection in young women?

The second most common cause of uncomplicated urinary tract infection in young women is Staphylococcus saprophyticus.

glomerulonephritis

The term glomerulonephritis implies inflammation of the glomerular basement membrane Antigen-antibody complexes are formed or deposited in the subepithelial or subendothelial areas; immune mediators follow, resulting in inflammatory injury Hematuria, overt or microscopic, is the hallmark of the disease Acute glomerulonephritis is an inflammation of glomeruli causing protein and RBC leakage into the urine, typically caused by an immune response Two types based on 24-hour urine protein Nephritic syndrome: moderate proteinuria 1-3.5 g/day Nephrotic syndrome: severe proteinuria > 3.5 g/day

Name three commonly used antibiotics for the treatment of uncomplicated cystitis:

Three commonly used antibiotics for the treatment of uncomplicated cystitis: 1. Trimethoprim-sulfamethoxazole (TMP-SMX) 2. Fluoroquinolones (Ciprofloxacin) 3. Nitrofurantoin

PHIMOSIS TREATMENT

Treat with betamethasone topically, if no improvement circumcision Phimosis → is normal in children and typically resolves by age 5 Betamethasone cream 0.05% BID to TID applied to the tip of the foreskin and the area touching the glans for 3 mo. is often effective Stretching the foreskin gently with two fingers or over an erect penis for 2 to 3 wks. with care not to cause paraphimosis is also successful If conservative measures are ineffective, circumcision is the preferred surgical option Treatment is not required in the absence of complications such as balanitis, UTIs, urinary outlet obstruction, unresponsive dermatologic disease, or suspicion of carcinoma

Cryptochidism treatment

Treat with surgery (orchiopexy) by age 1 The current recommendation is to correct as soon as possible after 4 months of age If not descended by 6 months and before he is 12 months old surgery (orchiopexy) should be performed. Undescended testes can be monitored for spontaneous descent over the first 4-6 months of life If still non-palpable at 4-6 mo well-child exam, refer to urology/surgery for evaluation and possible orchiopexy

HYDROCELE TREATMENT

Treatment usually involves watchful waiting. In rare circumstances, surgery is needed Most hydroceles will resolve within the first 12 months of life without treatment and do not need to be reassessed unless present after 1-year Infants: will usually close within the 1'st year of life may require elective repair as clinically indicated If elective repair is indicated treatment consists of needle aspiration or surgery

Rapidly progressive glomerulonephritis treatment

Treatments directed toward correction of fluid overload, HTN, uremia and inflammatory injury to the kidney. Includes corticosteroids, cytotoxic agents and plasmapheresis. Dialysis therapy and transplantation are used as maintenance therapy. May occur again after transplantation.

TESTICULAR TORSION DIAGNOSIS

U/S with doppler Testicular doppler for diagnosis = best initial test

CYSTITIS DIAGNOSIS

UA = esterase + WBC + nitrate + blood Screening urinalysis indicates pyuria (> 5 WBCs/HPF) in most children with UTI Urine culture is the gold standard for diagnosis. Susceptibility testing should be performed Urine dipstick ⇒ nitrite, leukocyte esterase (enzyme created by white blood cells) Urinalysis: pyuria (white blood cells in urine), bacteriuria, +/− hematuria, +/− nitrites Urine culture (gold standard) > 100,000 CFU/mL (women) In toilet-trained older children a midstream, a clean-catch method is usually satisfactory In infants and younger children, bladder catheterization or suprapubic collection is necessary in most cases to avoid contaminated samples

A 5-year-old presents to your office complaining of scrotal pain and you note swelling of the left testis. What is the appropriate next step?

Ultrasound evaluation with Doppler color flow

cryptorchidism DIAGNOSIS

Ultrasound may be helpful in identifying undescended testicles in abdominal space Thorough GU exam, including an attempt to "milk" inguinally located testes into the scrotum

what is the gold standard for the diagnosis of cystitis

Urine culture is the gold standard for diagnosis.

What are the characteristic laboratory findings of postinfectious GN?

Urine sediment reveals dysmorphic RBCs or RBC casts and proteinuria (occasionally nephrotic range); serum studies are remarkable for hypocomplementemia, positive ASO titer.

Patient will present as → a 1-year-old female with a temperature of 103.1 and irritability. A culture of a urine specimen is obtained and shows more than 106 colony-forming units of pansensitive Escherichia coli per milliliter. She is treated with intravenous ampicillin for several days, followed by oral ampicillin, for a total of 14 days of therapy. After the patient no longer had a fever and a urine culture was sterile, voiding cystourethrography was performed while the patient was still receiving ampicillin. The voiding cystourethrogram demonstrates bilateral grade III vesicoureteral reflux, and renal ultrasonography revealed normal findings.

VESICOURETHRAL REFLUX

What is the typical clinical presentation of MPGN?

Variable decrease in renal function, HTN, anemia, hematuria, and proteinuria

What are the characteristic laboratory findings of MPGN?

Variable increase in BUN/serum creatinine, anemia, low serum C3 or C4, and presence of serum C3 nephritic factor (especially in type II). Urine sediment contains dysmorphic RBCs, WBCs, and RBC casts

What are the signs of testicular torsion?

Very tender, swollen, elevated testicle; non-illumination; absence of cremasteric reflex (elevation of the testes in response to stroking of the inner thigh)

In young female patients, any history that points to recurrent infection, especially cystitis or pyelonephritis, should trigger an evaluation for what?

Vesicoureteral reflux (VUR)

What is vesicoureteral reflux (VUR)?

Vesicoureteral reflux is a condition in which urine flows backward from the bladder into the urinary tracts Vesicoureteral reflux (VUR) is a condition in which urine flows retrograde, or backward, from the bladder into the ureters/kidneys

Goodpasture syndrome

What type II hypersensitivity disorder is defined as • Autoantibodies against the type IV collagen in the basement membrane of the kidneys and lungs?

Alport syndrome

X-linked defect in Type IV collagen. Results in thinning/splitting of basement membrane. Clinical symptoms are: Isolated hematuria, sensory hearing loss and ocular disturbances. Presents as isolated persistent hematuria A genetic condition that occurs in children resulting in renal failure and hearing loss Ophthalmologic exam reveals anterior lenticonus - anterior part of the lens has a conical shape DX - C3 and C4 Levels

Is paraphimosis a urological emergency?

Yes - Paraphimosis should be regarded as an emergency because constriction leads quickly to vascular compromise and necrosis of the glans penis

epispadias

a congenital abnormality in males in which the urethra is on the upper surface of the penis Epispadias is when the urethra opens onto the topside (dorsal) of the penile shaft

hydrocele

a fluid-filled sac in the scrotum along the spermatic cord leading from the testicles A Hydrocele is a collection of fluid around the testicle or along the spermatic cord leading to a non-tender fluid-filled (cystic) mass This occurs when lymphatic drainage from the scrotum is impaired, leading to swelling and enlargement Hydrocele is common in newborns and typically disappears without treatment during the first year of life. However, treatment is indicated if the mass becomes large and uncomfortable

testicular torsion

a sharp pain in the scrotum caused by twisting of the vas deferens and blood vessels leading into the testicle Caused by a twisting of the testicle around the cord supplying blood to the scrotum Twisting of the spermatic cord that results in compromised blood flow and ischemia - this is considered a surgical emergency

A 15-year-old boy comes to the office because of malaise, anorexia, nausea, and decreased urination. His mother says that he is having problems hearing. Physical examination shows decreased hearing bilaterally with the Rinne test and bilateral edema in the lower extremities. Urinalysis shows microscopic hematuria and proteinuria. A peripheral blood smear reveals microcytic anemia

alport syndrome

enuresis

bed-wetting; involuntary passing of urine in children after bladder control is achieved Enuresis is the involuntary loss of urine in a child older than 5 years Successful bladder control is usually achieved between the ages of 24 and 36 months, although many developmentally normal children take significantly longer Age: > five years old

Paraphimosis

condition in which a retracted prepuce cannot be pulled forward to cover the glans Paraphimosis is an inability to return the foreskin to normal position Entrapment of the foreskin behind glans Causes a tourniquet effect and is a medical emergency More acute than phimosis Paraphimosis - is the entrapment of the foreskin in the retracted position => it is a medical emergency

hypospadias

congenital abnormality in which the male urethral opening is on the undersurface of the penis, instead of at its tip Hypospadias (more common than epispadias) is when the urethra opens onto the bottom (underside) of the penile shaft Hypospadias (more common than epispadias) is when the urethra opens onto the bottom/underside (ventral) of the penile shaft

primary vesicoureteral reflux

congenital/incompetence of valve Primary vesicoureteral reflux is the most common type and happens when a child is born with a defect at the ureterovesical junction

Goodpasture Syndrome Treatment

corticosteroids, immunosuppressive drugs, plasmapheresis, dialysis treat with high dose steroids, plasmapheresis + cyclophosphamide

Rapidly progressive glomerulonephritis

crescent formation on biopsy due to fibrin and plasma protein deposition Goodpasture's syndrome: (+) anti-GBM antibodies, dx linear IgG deposits, treat with high dose steroids, plasmapheresis + cyclophosphamide Vasculitis - lack of immune deposits (+) ANCA antibodies Microscopic polyangiitis (+) P-ANCA Granulomatosis with polyangiitis (Wegener's) (+) C-ANCA

primary enuresis

diagnosed in a child who never established urinary continence never had bladder control Primary enuretics: patients who have never successfully maintained a dry period. Primary nocturnal enuresis is thought to be due to delayed maturational control or inadequate levels of ADH secretion during sleep

vesicoureteral reflux

disorder caused by the failure of urine to pass through the ureters to the bladder, usually due to impairment of the valve between the ureter and bladder or obstruction in the ureter Vesicoureteral reflux (VUR) is a condition in which urine flows retrograde, or backward, from the bladder into the ureters/kidneys In young female patients, any history that points to recurrent infection, especially cystitis or pyelonephritis, should trigger an evaluation for vesicoureteral reflux (VUR)

What is the hallmark symptom of cystitis?

dysuria

NEPHRITIC SYNDROME PRESENTATION

edema + HTN + hematuria + RBC Casts/dysmorphic RBCs + proteinuria 1-3.5 g/day + azotemia The clinical picture is often accompanied by hypertension, peripheral edema, periorbital edema, and impaired renal function (oliguria 80 - 400 ml/day) Urinalysis: proteinuria < 3.5 grams per day, hematuria, RBC casts vs. a kidney stone which will have no RBC casts and RBCs are not dysmorphic

A 16 year-old male presents with increasing pain and swelling of his right scrotum. The right testicle is extremely tender to palpation on examination. A Doppler ultrasound demonstrates decreased blood flow. Which of the following is the most appropriate intervention?

emergent surgery

Patient will present as → a 5-year-old boy who comes to the emergency department because of enuresis for 1 month. His mother says he recently started kindergarten and is afraid he will have an accident during nap time. He stopped wetting the bed for almost 2 years and then suddenly started again with no recent change in diet or fluid intake. He has no history of daytime incontinence.

enuresis

orchiopexy

fixation of an undescended testis in the scrotum

Patient will present as → a 5-year-old female is brought to the office by her mother because of "coke colored" urine for a day. Three weeks ago, she was given antibiotics for impetigo. Past medical history is noncontributory. Her temperature is 36.5°C (97.7°F), pulse is 72/min, respirations are 14/min, and blood pressure is 134/86 mm Hg. Urine microscopy demonstrates dysmorphic erythrocytes and red blood cell casts. The result of a 24-hour urine collection is 2.6 g of protein/24 hr.

glomerulonephritis

Patient will present as → a 27-year-old male presents to the clinic complaining of coughing up small amounts of blood daily for the past week. He denies smoking, sick contacts, or recent travel. Chest radiographs demonstrate interstitial pneumonia with patchy alveolar infiltrates suggestive of multiple bleeding sites. Urinalysis is positive for blood and protein. A positive result is returned for anti-glomerular basement membrane antibody (anti-GBM Ab)

good pasture syndrome

glomerulonephritis diagnosis

history, physical examination, urinalysis, blood chemistry, serum antibody levels, computed tomography, and renal biopsy Urinalysis reveals hematuria (>3 RBCs / high power field) and RBC will be misshaped due to their passage through the glomerulus (RBC casts), and proteinuria (1-3.5 g/24 hours) Serum complement (C3) is often decreased Renal biopsy is the GOLD STANDARD may be done to determine the exact diagnosis and severity of the disease An antistreptolysin-o titer is increased in 60-80% of cases and should be considered if there is a possibility of recent streptococcal infection

+) Transillumination test of scrotum; Dx?

hydrocele

Patient will present as → a 1-day-old male infant born by normal spontaneous vaginal delivery was found to have a scrotal mass on physical examination. The mass transilluminates and confirms your suspicion of hydrocele.

hydrocele

Post-streptococcal glomerulonephritis

initial strep sore throat, skin infection (specific strain) -> lag period of 1-4 weeks after initial infection -> develop acute malaise, fever, oliguria, hematuria, hypertension (increased BUN and creatinin), periorbital edema -> antibodies to strep produced and circulate in the blood (type III hypersensitivity) -> strep antigens and antibodies form complexes that circulate in blood and get deposited in the basement membrane of the glomeruli -> activate complement and induce acute inflammation -> resolves spontaneously in most patients (DON'T TREAT) -> serum level of complement is low

Microscopic polyangitis

lungs, kidney and skin awith auci immune glomerulonephritis and palpable purpura necrotizing vasculitis presentation similar without the nasopharynx and panca treat with cyclophosphamide and steroids

a 26-year-old man who presents with hematuria, periorbital edema, and jaundice. He has a medical history of opioid use disorder with prior hospitalizations for a heroin overdose. He is on Suboxone but is non-adherent. His blood pressure is 162/102 mmHg. Physical examination is significant for scleral icterus, hepatomegaly, and palpable purpura. Serology shows decreased C3 and C4 levels and elevated anti-hepatitis C antibodies. Urinalysis demonstrates dysmorphic red blood cells and red blood cell casts.

membranoproliferative glomerulonepritis

p-anca

microscopic polyangiitis

secondary enuresis

occurs in a child who has had at least 6 months of nighttime dryness onset of wetting after established urinary continence Secondary enuretics: dry for several months before regular wetting occurs

IgA nephropathy PRESENTATION

presents/flares with a URI or acute gastroenteritis; episodic hematuria with RBC casts -children & young adults: gross hematuria 1-3 days after upper respiratory infection Gross hematuria and flank pain in a person with acute URI Often affects young males within days (24-48 hours) after URI or GI infection Caused by IgA immune complexes which are the first line of defense in respiratory and GI secretions so infections cause an overproduction which then damages the kidneys Diagnosed by (+) IgA deposits in mesangium and with immunostaining Renal biopsy alone makes the diagnosis demonstrating mesangial deposits of IgA in the glomeruli Slowly progresses to renal failure in 25% of cases

hydrocele

scrotal swelling caused by a collection of fluid A Hydrocele is a collection of fluid around the testicle or along the spermatic cord leading to a non-tender fluid-filled (cystic) mass A hydrocele is a mass of the fluid-filled congenital remnants of the tunica vaginalis, usually resulting from a patent processus vaginalis Hydrocele is common in newborns and typically disappears without treatment during the first year of life